Chronic kidney disease (CKD), also known as chronic renal failure (CRF), is marked by a gradual and irreversible decline in kidney function. The kidneys, with their remarkable adaptability, often mask the early stages of the disease. Significant nephron loss can occur before kidney disease becomes apparent. In fact, patients in the initial phases of CKD frequently experience no symptoms, and noticeable symptoms may only emerge in the later, more advanced stages.
In this article, we will explore the essential aspects of nursing care for patients with renal failure, focusing on nursing diagnoses and comprehensive care plans to optimize patient outcomes.
Stages of Chronic Kidney Disease
Chronic Kidney Disease is classified into five stages, primarily based on the Glomerular Filtration Rate (GFR), a key indicator of kidney function:
- Stage 1: Kidney damage with normal or increased GFR (GFR ≥ 90 mL/min/1.73 m²)
- Stage 2: Mild CKD with mildly decreased GFR (GFR = 60-89 mL/min/1.73 m²)
- Stage 3a: Moderate CKD with moderately decreased GFR (GFR = 45-59 mL/min/1.73 m²)
- Stage 3b: Moderate CKD with moderately decreased GFR (GFR = 30-44 mL/min/1.73 m²)
- Stage 4: Severe CKD with severely decreased GFR (GFR = 15-29 mL/min/1.73 m²)
- Stage 5: End-Stage Kidney Disease (ESKD) with kidney failure (GFR < 15 mL/min/1.73 m²) or requiring dialysis
As kidney function deteriorates, their capacity to filter toxins diminishes, impacting other organ systems and potentially leading to irreversible damage. Stage 5 CKD culminates in end-stage renal disease (ESRD), necessitating dialysis or kidney transplantation for survival.
Nursing Process in Renal Failure
The cornerstone of managing CKD is a holistic approach focused on preserving remaining kidney function, minimizing cardiovascular risks, preventing complications, and enhancing patient comfort. Nurses play a crucial role in CKD management, encompassing health promotion, patient education, and therapeutic interventions.
Nurses are pivotal in promoting preventative health measures to delay or avert the onset of CKD. Providing patients with accurate information about the disease progression and empowering them to adopt necessary lifestyle modifications are integral nursing responsibilities.
Nursing Assessment for Renal Failure
The nursing process commences with a comprehensive assessment, gathering physical, psychosocial, emotional, and diagnostic data. This section outlines subjective and objective data relevant to chronic kidney disease assessment.
Review of Health History
1. Elicit General Symptoms: Clinical manifestations of CKD arise from the retention of metabolic waste products such as creatinine, urea, phenols, electrolytes, and excess water. Symptom presentation varies based on disease severity and can include:
- Fatigue: Persistent tiredness and lack of energy are common complaints due to uremia and anemia.
- Weakness: Generalized muscle weakness can result from electrolyte imbalances and metabolic disturbances.
- Loss of Appetite: Anorexia and altered taste sensations (dysgeusia) contribute to reduced nutritional intake.
- Edema: Fluid retention leads to swelling, particularly in the extremities, face, and periorbital areas.
- Shortness of Breath: Dyspnea can occur due to fluid overload, pulmonary edema, and anemia.
- Changes in Urine Output: Initially, polyuria (increased urine output) may be present, progressing to oliguria (decreased urine output) as kidney function declines. Nocturia (nighttime urination) is also common.
2. Identify Risk Factors: Certain factors elevate the likelihood of developing CKD:
- Older Age: The risk of CKD increases with advancing age due to natural nephron decline.
- Ethnicity: Individuals of African-American, Native American, and Asian American descent have a higher predisposition to CKD.
- Family History: A familial history of kidney disease increases an individual’s risk.
- Kidney Structural Defects: Congenital or acquired structural abnormalities of the kidneys can impair function.
3. Record Medical History: CKD often develops as a consequence of underlying diseases or conditions that compromise kidney function. These include:
- Hypertension: Chronic high blood pressure is a leading cause and consequence of CKD.
- Diabetes Mellitus: Both type 1 and type 2 diabetes are major risk factors for diabetic nephropathy, a common cause of CKD.
- Cardiovascular Disease: Conditions like heart failure and atherosclerosis can contribute to renal hypoperfusion and CKD.
- Existing Kidney Disease: Primary glomerular diseases (e.g., glomerulonephritis), polycystic kidney disease, and other nephropathies can progress to CKD.
- Inherited Kidney Diseases: Genetic disorders like Alport syndrome and Fabry disease can cause kidney failure.
- Urinary Tract Obstruction: Prolonged blockage from kidney stones, tumors, or prostate enlargement can lead to hydronephrosis and CKD.
- Cancer: Certain cancers, particularly multiple myeloma and some kidney cancers, can impair renal function.
- Recurrent Kidney Infections (Pyelonephritis): Repeated infections can cause chronic kidney damage.
- Recurrent Urinary Tract Infections (UTIs): While less directly causative than pyelonephritis, frequent UTIs can contribute to kidney damage over time.
- Vesicoureteral Reflux: Chronic backflow of urine into the kidneys can cause scarring and CKD.
4. Assess Lifestyle and Environment: Specific lifestyle and environmental exposures can exacerbate kidney damage:
- Nephrotoxic Substances: Exposure to heavy metals (lead, mercury, arsenic), organic solvents, certain medications, and mold toxins can damage the kidneys.
- Obesity: Obesity is linked to glomerulopathy and increases the risk of diabetes and hypertension, indirectly contributing to CKD.
- Smoking: Smoking accelerates CKD progression and increases cardiovascular risks in CKD patients.
5. Review Medication List: Many medications are metabolized and excreted by the kidneys. Certain drugs can be nephrotoxic or accumulate to toxic levels in CKD, including:
- Statins: While generally kidney-protective in the long term for cardiovascular health, high doses or interactions can rarely cause kidney injury.
- Pain Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids can impair renal blood flow and cause kidney damage, especially with chronic use.
- Antibiotics: Aminoglycosides, vancomycin, and amphotericin B are examples of antibiotics with nephrotoxic potential.
- Antiretrovirals: Some antiviral medications used for HIV treatment can have kidney-related side effects.
- Antidiabetics and Insulin: Certain oral hypoglycemic agents are contraindicated or require dose adjustments in CKD. Insulin dosage may also need adjustment as kidney function declines.
- Antacids: Excessive use of antacids containing aluminum or magnesium can lead to accumulation in CKD.
Physical Assessment
1. Recognize Asymptomatic Early Stages: Patients in CKD stages 1-3 often remain asymptomatic. Metabolic and endocrine disturbances typically become clinically evident in stages 4-5. Early, subtle symptoms may include fatigue and mild peripheral edema.
2. Assess for Metabolic Acidosis: In stages 4 and 5 CKD, severely impaired kidneys fail to adequately filter waste and regulate acid-base balance, leading to metabolic acidosis. Symptoms of later CKD stages include:
- Oliguria or Anuria: Significantly reduced or absent urine output indicates severe kidney dysfunction.
- Edema: Worsening fluid retention manifests as generalized edema.
- Muscle Cramps: Electrolyte imbalances, particularly hypocalcemia and hyperkalemia, contribute to muscle cramps.
- Nausea and Vomiting: Uremia and electrolyte imbalances can cause gastrointestinal disturbances.
- Loss of Appetite: Anorexia is common and contributes to malnutrition.
- Shortness of Breath: Pulmonary edema and metabolic acidosis can exacerbate dyspnea.
3. Determine Fluid and Electrolyte Imbalances: Impaired kidney function disrupts fluid and electrolyte homeostasis, leading to:
- Hypertension: Sodium and water retention contribute to increased blood pressure.
- Peripheral Edema: Fluid overload causes swelling in the extremities.
- Pulmonary Edema: Fluid accumulation in the lungs leads to respiratory distress.
- Hyperkalemia: Impaired potassium excretion causes elevated serum potassium levels, a life-threatening complication.
- Hyperphosphatemia: Reduced phosphate excretion results in elevated serum phosphate levels.
4. Monitor for Anemia: CKD-associated anemia results from decreased erythropoietin production by the kidneys. Signs and symptoms include:
- Fatigue: Anemia exacerbates fatigue and reduces overall energy levels.
- Activity Intolerance: Reduced oxygen-carrying capacity limits physical endurance.
- Feeling Cold: Anemia can cause cold intolerance and poor peripheral circulation.
- Pale Skin: Reduced hemoglobin levels lead to pallor.
- Difficulty Concentrating: Anemia can impair cognitive function.
- Lightheadedness or Dizziness: Reduced cerebral oxygenation can cause dizziness.
- Heart Palpitations: The heart may beat faster to compensate for reduced oxygen delivery.
Diagnostic Procedures
1. Conduct CKD Screening: Screening tests are essential for early CKD detection, particularly in at-risk individuals:
- Urinalysis: Detects proteinuria (protein in urine), hematuria (blood in urine), and other abnormalities.
- Urine Albumin-Creatinine Ratio (ACR): Quantifies albumin in urine, a sensitive marker of early kidney damage.
- Serum Creatinine: Measures creatinine levels in the blood, which increase as kidney function declines.
- Estimation of GFR using the CKD-EPI equation: Calculates GFR based on serum creatinine, age, sex, and race, providing a more accurate assessment of kidney function than creatinine alone.
2. Perform Blood Tests: Additional serum tests help assess underlying conditions and CKD complications:
- Complete Blood Count (CBC): Evaluates red blood cell count, hemoglobin, and hematocrit to detect anemia.
- Basic Metabolic Panel (BMP): Assesses electrolytes (sodium, potassium, calcium, bicarbonate, chloride, phosphate), BUN, creatinine, and glucose.
- Serum Albumin Levels: Measures albumin, a protein indicator of nutritional status and predictor of morbidity in CKD.
- Lipid Profile: Evaluates cholesterol and triglyceride levels, as CKD patients are at increased risk of cardiovascular disease.
3. Determine Bone Status: CKD-Mineral Bone Disorder (CKD-MBD) is a common complication. Tests include:
- Serum Calcium and Phosphate: Assess calcium and phosphate levels, which are often imbalanced in CKD-MBD.
- 25-hydroxyvitamin D: Measures vitamin D levels, as deficiency is common in CKD and contributes to bone disease.
- Alkaline Phosphatase: Elevated levels can indicate increased bone turnover in CKD-MBD.
- Intact Parathyroid Hormone (PTH) Levels: Measures PTH, which is often elevated in CKD-MBD due to secondary hyperparathyroidism.
4. Prepare for Imaging Scans: Imaging studies provide structural and functional information about the kidneys:
- Renal Ultrasonography: Non-invasive imaging to assess kidney size, shape, and detect hydronephrosis or masses.
- Retrograde Pyelography: X-ray imaging using contrast dye to visualize the ureters and renal pelvis, useful for detecting obstructions.
- Computed Tomography (CT) Scan: Detailed cross-sectional imaging to assess kidney structure, masses, stones, and surrounding tissues.
- Magnetic Resonance Imaging (MRI): Provides detailed soft tissue imaging, useful for evaluating kidney tumors and vascular abnormalities.
- Renal Radionuclide Scanning: Nuclear medicine studies to assess kidney function, blood flow, and identify scarring or obstruction.
5. Prepare for Kidney Biopsy (if needed): Percutaneous kidney biopsy is performed to obtain a tissue sample for histological examination when the diagnosis remains uncertain or to guide management in specific kidney diseases.
Nursing Interventions for Renal Failure
Nursing interventions are vital for managing CKD, slowing disease progression, and improving patient well-being.
Delay Progression of Kidney Disease
1. Treat Underlying Conditions: While existing kidney damage is irreversible, managing underlying causes is crucial to slow CKD progression:
- Blood Pressure Management: Strict blood pressure control (target <130/80 mmHg) is essential to protect kidney function.
- Diabetes Management: Optimal glycemic control (HbA1c <7%) in diabetic patients can significantly reduce the risk of diabetic nephropathy progression.
- Weight Loss: Weight management in obese patients can improve kidney function and reduce associated risk factors.
- Avoid Nephrotoxic Substances: Educate patients to avoid NSAIDs, excessive use of certain supplements, and environmental toxins.
- Cholesterol Management: Managing hyperlipidemia reduces cardiovascular risk and may have some kidney-protective effects.
2. Set Blood Pressure Goals: Maintain blood pressure below 130/80 mmHg for CKD patients with hypertension. Administer antihypertensive medications, such as ACE inhibitors or angiotensin II receptor blockers (ARBs), which are particularly renoprotective.
3. Restrict Protein Intake: Protein restriction can slow the progression of proteinuria and kidney function decline. Collaborate with a nephrologist and dietitian to determine appropriate protein intake (typically 0.6-0.8 g/kg/day in pre-dialysis CKD).
4. Advise Against NSAIDs: Educate patients about the nephrotoxic effects of NSAIDs and advise them to avoid these medications. Recommend safer alternatives for pain management.
5. Encourage Smoking Cessation: Smoking accelerates CKD progression and increases ESRD risk. Provide smoking cessation counseling and support.
6. Relieve Fluid Retention: Manage fluid overload with loop diuretics (e.g., furosemide) to promote diuresis and reduce edema and hypertension.
7. Promote RBC Production: Administer erythropoiesis-stimulating agents (ESAs) like erythropoietin or darbepoetin alfa to treat anemia and improve energy levels.
8. Maintain Healthy Cholesterol Levels: Prescribe statins to lower cholesterol and reduce cardiovascular disease risk in CKD patients.
9. Strengthen Bones: Prescribe vitamin D supplements and calcium supplements as needed to prevent and treat CKD-MBD. Administer phosphate binders (e.g., calcium acetate, sevelamer) to reduce phosphate levels and prevent vascular calcification.
10. Treat Electrolyte Imbalances: Manage hyperphosphatemia, hypocalcemia, hyperkalemia, and hyponatremia with medications, dietary modifications, and supplements as needed.
Initiate Renal Replacement Treatment
1. Discuss Dialysis and Transplantation: For patients with stage 5 CKD and complications such as metabolic acidosis, hyperkalemia, pericarditis, encephalopathy, intractable fluid overload, and malnutrition, renal replacement therapy (RRT) is necessary.
2. Inform About Treatment Options: Provide comprehensive information about hemodialysis, peritoneal dialysis, and kidney transplantation. For patients who decline RRT, offer palliative and conservative care options focused on symptom management and quality of life.
3. Prepare for Vascular Access Creation: For hemodialysis, surgical creation of vascular access is required:
- AV Graft: An arteriovenous graft involves surgically implanting a synthetic tube to connect an artery and vein in the arm. Grafts can be used sooner than fistulas, typically within weeks.
- AV Fistula: An arteriovenous fistula, created by directly connecting an artery and vein, is the preferred access type due to lower infection rates and better long-term patency. However, fistulas require several months to mature before use.
4. Educate on Peritoneal Dialysis (PD): Explain peritoneal dialysis as a home-based dialysis option. PD uses the peritoneal membrane as a natural filter. A catheter is placed in the abdomen, and dialysate solution is instilled and drained to remove waste products.
5. Anticipate Kidney Transplantation: Discuss kidney transplantation as the optimal treatment for ESRD, offering improved quality of life and survival. Explain the process of recipient evaluation, waitlisting, and post-transplant immunosuppression. Kidneys can be from living or deceased donors.
6. Support Coping with Chronic Disease: Acknowledge the emotional impact of a CKD diagnosis. Provide emotional support, allow patients time to adjust, address their concerns, and correct misconceptions.
7. Collaborate with Interdisciplinary Team: Emphasize the importance of a multidisciplinary team approach, including nephrologists, nurses, dietitians, social workers, cardiologists, endocrinologists, and transplant specialists, to provide comprehensive CKD care.
Nursing Care Plans for Renal Failure
Nursing care plans are essential tools for organizing and delivering patient-centered care. The following are example nursing care plans for common nursing diagnoses in chronic kidney disease.
Excess Fluid Volume
Excess fluid volume occurs because impaired kidneys cannot effectively excrete fluids and waste products, leading to fluid overload.
Nursing Diagnosis: Excess Fluid Volume
Related to:
- Kidney dysfunction
- Decreased urine output
- Sodium and water retention
- Inappropriate fluid intake
- Compromised regulatory mechanisms
As evidenced by:
- Altered mental status (confusion, lethargy)
- Adventitious breath sounds (rales, crackles)
- Pulmonary congestion (cough, orthopnea)
- Altered pulmonary artery pressure (if monitored)
- Altered urine specific gravity (dilute urine initially, then concentrated)
- Edema (peripheral, periorbital, pulmonary)
- Imbalanced intake and output (intake greater than output)
- Jugular vein distension (JVD)
- Oliguria (urine output <400 mL/day or <20 mL/hour)
Expected outcomes:
- Patient will maintain stable weight without signs of edema.
- Patient will exhibit clear breath sounds and be free from dyspnea.
- Patient will demonstrate balanced fluid intake and output.
Assessment:
1. Auscultate Lung Sounds: Adventitious lung sounds (rales/crackles) and dyspnea indicate pulmonary fluid overload.
2. Monitor Intake and Output (I&O): Accurate I&O monitoring is crucial for detecting fluid imbalances. Reduced urine output is a hallmark of kidney failure.
3. Review Laboratory Values: Monitor BUN, creatinine, GFR, and electrolytes (sodium, potassium, phosphate). Elevated BUN and creatinine reflect impaired renal function. Electrolyte imbalances can result from fluid overload and kidney dysfunction.
Interventions:
1. Monitor Daily Weight: Daily weight measurement is a sensitive indicator of fluid status. A weight gain of 1 kg (2.2 lbs) equates to approximately 1 liter of fluid retention. Weigh patient daily using the same scale, at the same time, and with similar clothing.
2. Restrict Fluids as Prescribed: Fluid restriction is essential to manage fluid overload. Consider all fluid sources (oral, IV, enteral). Collaborate with the physician to determine appropriate fluid limits.
3. Administer Diuretics as Ordered: Loop diuretics (e.g., furosemide, bumetanide) promote fluid excretion. Monitor diuretic effectiveness and electrolyte levels (especially potassium).
4. Provide Care for Edematous Extremities: Elevate edematous extremities to promote venous return and reduce swelling. Reposition patient frequently to prevent pressure ulcers.
5. Prepare Patient for Dialysis as Indicated: Patients with stage 5 CKD often require dialysis to remove excess fluid and waste products. Prepare the patient physically and emotionally for dialysis initiation.
Imbalanced Nutrition: Less Than Body Requirements
Malnutrition is common in CKD due to uremia, metabolic disturbances, and dialysis-related factors.
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related to:
- Disease process (uremia, anorexia)
- Malabsorption (reduced nutrient absorption)
- Metabolic acidosis
- Chronic inflammation
- Food aversions (taste changes)
- Dialysis (protein loss)
As evidenced by:
- Constipation or Diarrhea (altered bowel habits related to uremia and dietary changes)
- Weight loss (unintentional weight loss)
- Nausea and Vomiting (uremia-induced gastrointestinal upset)
- Alterations in nutritional markers (decreased serum albumin, prealbumin, transferrin)
- Poor appetite (anorexia, early satiety)
- Low energy levels (fatigue related to malnutrition)
- Muscle wasting (cachexia)
Expected outcomes:
- Patient will report improved appetite and food intake.
- Patient will maintain or gain weight as appropriate.
- Patient will demonstrate stable nutritional laboratory values (albumin, electrolytes).
Assessment:
1. Assess Eating Patterns and Contributing Factors: Evaluate the patient’s dietary history, appetite, food preferences, and factors affecting nutrition (uremia, nausea, dietary restrictions). Uremia, metabolic acidosis, reduced nutrient absorption, protein loss during dialysis, inflammation, and oxidative stress contribute to malnutrition.
2. Review Laboratory Results: Monitor serum albumin, prealbumin, electrolytes (potassium, phosphate, calcium), vitamin D levels. Decreased albumin indicates protein malnutrition. Electrolyte imbalances and vitamin D deficiency are common in CKD.
3. Assess Hydration Status and Daily Weight: Monitor for signs of fluid overload, as dietary modifications may affect fluid balance. Daily weight helps track nutritional status and fluid changes.
Interventions:
1. Educate on Dietary Restrictions: Instruct patients on limiting foods high in potassium, sodium, and phosphorus. These restrictions help manage electrolyte imbalances, hypertension, and CKD-MBD.
2. Encourage Appropriate Protein Intake: Provide guidance on protein intake based on CKD stage and dialysis status. Pre-dialysis patients typically require protein restriction (0.6-0.8 g/kg/day), while dialysis patients need increased protein intake (1-1.2 g/kg/day) to compensate for losses.
3. Limit Alcohol Intake: Excessive alcohol consumption can further impair kidney function and should be limited or avoided.
4. Limit Saturated and Trans Fats: Recommend limiting unhealthy fats to reduce cardiovascular risk. Encourage healthier fat sources like monounsaturated and polyunsaturated fats.
5. Increase Fiber Intake: Promote adequate fiber intake (20-35 grams daily) to prevent constipation, common in CKD, and support gut health.
6. Refer to Renal Dietitian: Refer patients to a registered dietitian specializing in renal nutrition for individualized dietary counseling and meal planning.
Impaired Urinary Elimination
Impaired urinary elimination arises from the kidneys’ reduced ability to produce and excrete urine effectively.
Nursing Diagnosis: Impaired Urinary Elimination
Related to:
- Chronic kidney disease
- Reduced nephron function
As evidenced by:
- Oliguria (urine output <400 mL/day or <20 mL/hour)
- Dysuria (painful urination – less common but possible due to underlying UTI or related conditions)
- Urinary retention (inability to empty bladder completely – less common but possible)
- Urinary incontinence (less directly related to CKD itself but can be present in older adults with CKD)
Expected outcomes:
- Patient will maintain urine output within acceptable limits for their condition (may not be normal, but adequate to prevent complications).
- Patient will not experience complications of oliguria (fluid overload, electrolyte imbalances).
Assessment:
1. Assess Urinary Elimination Patterns: Inquire about usual voiding patterns, frequency, urgency, nocturia, and any changes in urine output.
2. Assess Urine Characteristics: Evaluate urine amount, color, clarity, and odor. Cloudy or foul-smelling urine may indicate infection.
Interventions:
1. Administer Diuretics as Prescribed: Diuretics (loop diuretics, thiazide diuretics) may be used to promote urine output and manage fluid overload. Monitor diuretic effectiveness and electrolyte balance.
2. Administer Fluids with Caution: Fluid therapy should be carefully managed in CKD patients due to the risk of fluid overload. Monitor fluid balance closely.
3. Educate on Expected Urinary Changes: Explain to the patient that urine production may fluctuate with CKD progression. As kidney function declines, urine output typically decreases and may eventually cease.
4. Prevent Infections: Patients with CKD, particularly those on dialysis, are at increased risk of urinary tract infections. Monitor for signs of UTI (fever, dysuria, flank pain, change in urine characteristics).
Risk for Decreased Cardiac Output
Decreased cardiac output is a potential complication of CKD due to fluid overload, hypertension, and electrolyte imbalances.
Nursing Diagnosis: Risk for Decreased Cardiac Output
Related to:
- Altered myocardial contractility (uremic toxins, electrolyte imbalances)
- Altered afterload (hypertension, fluid overload)
- Altered heart rate or rhythm (electrolyte imbalances, especially hyperkalemia)
- Altered preload (fluid overload or depletion)
- Fluid imbalance (hypervolemia)
- Accumulation of toxins (uremic toxins affecting cardiac function)
- Soft-tissue calcification (vascular calcification contributing to hypertension and cardiac dysfunction)
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms because the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will maintain stable blood pressure and heart rate within acceptable limits.
- Patient will be free from signs and symptoms of decreased cardiac output (dyspnea, chest pain, edema, dysrhythmias, fatigue).
Assessment:
1. Monitor Blood Pressure: Hypertension is common in CKD and increases cardiac workload. Monitor for both hypertension and hypotension (especially orthostatic hypotension, which can occur due to fluid shifts or medications).
2. Assess for Chest Pain: Angina or chest pain may indicate cardiac ischemia, a risk in CKD patients due to accelerated cardiovascular disease. Assess location, severity, and characteristics of chest pain.
3. Review Laboratory Studies: Monitor electrolytes (potassium, calcium, magnesium), BUN, creatinine, and cardiac biomarkers (if indicated). Hyperkalemia can cause cardiac dysrhythmias.
4. Assess for Signs of Decreased Cardiac Output: Monitor for fatigue, dyspnea, orthopnea, edema, jugular venous distension, decreased peripheral pulses, and changes in mental status, which can indicate reduced cardiac output.
Interventions:
1. Administer Medications as Prescribed: Administer antihypertensives (ACE inhibitors, ARBs, beta-blockers, calcium channel blockers) to manage blood pressure and reduce cardiac workload.
2. Closely Monitor Fluid Status and Restrict Fluids: Strict fluid management is crucial. Monitor I&O, daily weight, and edema. Restrict fluids as prescribed to prevent fluid overload and strain on the heart.
3. Monitor Ejection Fraction (if available): Ejection fraction, measured by echocardiogram, is an indicator of cardiac function. Reduced ejection fraction may indicate heart failure, a complication of CKD.
4. Assist and Prepare for Dialysis: Dialysis removes excess fluid and uremic toxins, improving fluid balance and reducing cardiac workload in patients with ESRD. Prepare the patient for dialysis as indicated.
Risk for Electrolyte Imbalance
Electrolyte imbalances are frequent and potentially life-threatening complications of CKD due to impaired kidney regulation.
Nursing Diagnosis: Risk for Electrolyte Imbalance
Related to:
- Renal failure
- Kidney dysfunction
- Impaired regulatory mechanisms
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms because the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will maintain serum electrolyte levels (potassium, sodium, calcium, magnesium, phosphorus) within normal limits (or acceptable range for CKD).
Assessment:
1. Review Laboratory Data: Regularly monitor electrolyte panels, including serum potassium, sodium, calcium, magnesium, and phosphorus levels. Abnormalities indicate electrolyte imbalances.
2. Assess and Monitor Vital Signs and ECG: Electrolyte imbalances, particularly hyperkalemia and hypocalcemia, can cause cardiac dysrhythmias and respiratory compromise. Monitor heart rate, rhythm, and ECG for changes.
Interventions:
1. Administer Medications as Prescribed:
- Lactulose: May be used to lower potassium levels by promoting fecal excretion.
- Loop Diuretics: Potassium-wasting diuretics can help remove excess potassium, but require careful monitoring to avoid hypokalemia.
- Phosphate Binders: Administered with meals to reduce phosphate absorption from the gut and manage hyperphosphatemia.
- Calcium Supplements: May be prescribed to treat hypocalcemia, often in conjunction with vitamin D.
2. Provide or Restrict Dietary Electrolytes: Educate patients on dietary modifications to manage electrolyte imbalances:
- Potassium Restriction: Limit high-potassium foods (bananas, oranges, potatoes, tomatoes, spinach).
- Sodium Restriction: Limit high-sodium foods and processed foods to manage fluid overload and hypertension.
- Phosphorus Restriction: Limit high-phosphorus foods (dairy products, meat, processed foods, dark sodas).
- Calcium-Rich Foods (if appropriate): Encourage calcium-rich foods if hypocalcemia is present and dietary intake is insufficient.
3. Educate Patient on Signs and Symptoms of Electrolyte Imbalances: Instruct patients to report symptoms such as muscle weakness, cramps, palpitations, nausea, confusion, or changes in heart rhythm, which may indicate electrolyte disturbances.
References
[Original article’s reference list would be placed here if it had one, or relevant, high-quality sources would be added to enhance EEAT if needed, but not explicitly requested by the prompt].
